White Rock Medical Center

All Charges

Charge

Type

Setting

Price

MAJOR SKIN DISORDERS WITH MCC

Facility

$40,686.60

Service Code	MSDRG 595
Min. Negotiated Rate	$17,087.34
Max. Negotiated Rate	$40,686.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$20,302.75
Rate for Payer: Amerigroup Medicare	$20,302.75
Rate for Payer: BCBS of TX Medicare	$20,302.75
Rate for Payer: Cigna Commercial	$27,314.62
Rate for Payer: Cigna Medicare	$20,302.75
Rate for Payer: Employer Direct Commercial	$20,302.75
Rate for Payer: Humana Medicare/TRICARE	$20,302.75
Rate for Payer: Molina Dual Medicare/Medicaid	$20,302.75
Rate for Payer: Molina Medicare	$20,302.75
Rate for Payer: Multiplan Auto	$40,686.60
Rate for Payer: Multiplan Commercial	$40,686.60
Rate for Payer: Multiplan Workers Comp	$40,686.60
Rate for Payer: Scott and White EPO/PPO	$18,737.25
Rate for Payer: Scott and White Medicare	$20,302.75
Rate for Payer: Superior Health Plan EPO	$20,302.75
Rate for Payer: Superior Health Plan Medicare	$20,302.75
Rate for Payer: Universal American Dual Medicare/Medicaid	$20,302.75
Rate for Payer: Universal American Medicare	$20,302.75
Rate for Payer: Wellcare Medicare	$20,302.75
Rate for Payer: Wellmed Medicare	$20,302.75

MAJOR SKIN DISORDERS WITHOUT MCC

Facility

$20,744.20

Service Code	MSDRG 596
Min. Negotiated Rate	$8,698.90
Max. Negotiated Rate	$20,744.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$12,693.76
Rate for Payer: Amerigroup Medicare	$12,693.76
Rate for Payer: BCBS of TX Medicare	$12,693.76
Rate for Payer: Cigna Commercial	$13,942.60
Rate for Payer: Cigna Medicare	$12,693.76
Rate for Payer: Employer Direct Commercial	$12,693.76
Rate for Payer: Humana Medicare/TRICARE	$12,693.76
Rate for Payer: Molina Dual Medicare/Medicaid	$12,693.76
Rate for Payer: Molina Medicare	$12,693.76
Rate for Payer: Multiplan Auto	$20,744.20
Rate for Payer: Multiplan Commercial	$20,744.20
Rate for Payer: Multiplan Workers Comp	$20,744.20
Rate for Payer: Scott and White EPO/PPO	$9,553.25
Rate for Payer: Scott and White Medicare	$12,693.76
Rate for Payer: Superior Health Plan EPO	$12,693.76
Rate for Payer: Superior Health Plan Medicare	$12,693.76
Rate for Payer: Universal American Dual Medicare/Medicaid	$12,693.76
Rate for Payer: Universal American Medicare	$12,693.76
Rate for Payer: Wellcare Medicare	$12,693.76
Rate for Payer: Wellmed Medicare	$12,693.76

MAJOR SKIN DISORDERS W MCC

Facility

$40,686.60

Service Code	MSDRG 595
Min. Negotiated Rate	$17,087.34
Max. Negotiated Rate	$40,686.60
Rate for Payer: BCBS of TX Blue Advantage	$17,087.34
Rate for Payer: BCBS of TX Blue Essentials	$20,502.82
Rate for Payer: BCBS of TX PPO	$22,781.80

MAJOR SKIN DISORDERS W/O MCC

Facility

$20,744.20

Service Code	MSDRG 596
Min. Negotiated Rate	$8,698.90
Max. Negotiated Rate	$20,744.20
Rate for Payer: BCBS of TX Blue Advantage	$8,698.90
Rate for Payer: BCBS of TX Blue Essentials	$10,437.67
Rate for Payer: BCBS of TX PPO	$11,597.86

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$46,652.60

Service Code	MSDRG 330
Min. Negotiated Rate	$21,484.75
Max. Negotiated Rate	$46,652.60
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$22,329.23
Rate for Payer: Amerigroup Medicare	$22,329.23
Rate for Payer: BCBS of TX Medicare	$22,329.23
Rate for Payer: Cigna Commercial	$30,875.94
Rate for Payer: Cigna Medicare	$22,329.23
Rate for Payer: Employer Direct Commercial	$22,329.23
Rate for Payer: Humana Medicare/TRICARE	$22,329.23
Rate for Payer: Molina Dual Medicare/Medicaid	$22,329.23
Rate for Payer: Molina Medicare	$22,329.23
Rate for Payer: Multiplan Auto	$46,652.60
Rate for Payer: Multiplan Commercial	$46,652.60
Rate for Payer: Multiplan Workers Comp	$46,652.60
Rate for Payer: Scott and White EPO/PPO	$21,484.75
Rate for Payer: Scott and White Medicare	$22,329.23
Rate for Payer: Superior Health Plan EPO	$22,329.23
Rate for Payer: Superior Health Plan Medicare	$22,329.23
Rate for Payer: Universal American Dual Medicare/Medicaid	$22,329.23
Rate for Payer: Universal American Medicare	$22,329.23
Rate for Payer: Wellcare Medicare	$22,329.23
Rate for Payer: Wellmed Medicare	$22,329.23

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$87,842.70

Service Code	MSDRG 329
Min. Negotiated Rate	$38,447.94
Max. Negotiated Rate	$87,842.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$38,447.94
Rate for Payer: Amerigroup Medicare	$38,447.94
Rate for Payer: BCBS of TX Medicare	$38,447.94
Rate for Payer: Cigna Commercial	$59,202.92
Rate for Payer: Cigna Medicare	$38,447.94
Rate for Payer: Employer Direct Commercial	$38,447.94
Rate for Payer: Humana Medicare/TRICARE	$38,447.94
Rate for Payer: Molina Dual Medicare/Medicaid	$38,447.94
Rate for Payer: Molina Medicare	$38,447.94
Rate for Payer: Multiplan Auto	$87,842.70
Rate for Payer: Multiplan Commercial	$87,842.70
Rate for Payer: Multiplan Workers Comp	$87,842.70
Rate for Payer: Scott and White EPO/PPO	$40,453.88
Rate for Payer: Scott and White Medicare	$38,447.94
Rate for Payer: Superior Health Plan EPO	$38,447.94
Rate for Payer: Superior Health Plan Medicare	$38,447.94
Rate for Payer: Universal American Dual Medicare/Medicaid	$38,447.94
Rate for Payer: Universal American Medicare	$38,447.94
Rate for Payer: Wellcare Medicare	$38,447.94
Rate for Payer: Wellmed Medicare	$38,447.94

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$32,467.20

Service Code	MSDRG 331
Min. Negotiated Rate	$14,574.42
Max. Negotiated Rate	$32,467.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$17,094.09
Rate for Payer: Amerigroup Medicare	$17,094.09
Rate for Payer: BCBS of TX Medicare	$17,094.09
Rate for Payer: Cigna Commercial	$21,675.75
Rate for Payer: Cigna Medicare	$17,094.09
Rate for Payer: Employer Direct Commercial	$17,094.09
Rate for Payer: Humana Medicare/TRICARE	$17,094.09
Rate for Payer: Molina Dual Medicare/Medicaid	$17,094.09
Rate for Payer: Molina Medicare	$17,094.09
Rate for Payer: Multiplan Auto	$32,467.20
Rate for Payer: Multiplan Commercial	$32,467.20
Rate for Payer: Multiplan Workers Comp	$32,467.20
Rate for Payer: Scott and White EPO/PPO	$14,952.00
Rate for Payer: Scott and White Medicare	$17,094.09
Rate for Payer: Superior Health Plan EPO	$17,094.09
Rate for Payer: Superior Health Plan Medicare	$17,094.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$17,094.09
Rate for Payer: Universal American Medicare	$17,094.09
Rate for Payer: Wellcare Medicare	$17,094.09
Rate for Payer: Wellmed Medicare	$17,094.09

MAJOR SMALL BOWEL PROCEDURES

Facility

$6,716.98

Service Code	APR-DRG 2301
Min. Negotiated Rate	$6,333.01
Max. Negotiated Rate	$6,716.98
Rate for Payer: Amerigroup CHIP/Medicaid	$6,333.01
Rate for Payer: Cigna Medicaid	$6,333.01
Rate for Payer: Molina CHIP/Medicaid	$6,333.01
Rate for Payer: Parkland Medicaid	$6,333.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,716.98

MAJOR SMALL BOWEL PROCEDURES

Facility

$14,661.34

Service Code	APR-DRG 2303
Min. Negotiated Rate	$13,823.22
Max. Negotiated Rate	$14,661.34
Rate for Payer: Amerigroup CHIP/Medicaid	$13,823.22
Rate for Payer: Cigna Medicaid	$13,823.22
Rate for Payer: Molina CHIP/Medicaid	$13,823.22
Rate for Payer: Parkland Medicaid	$13,823.22
Rate for Payer: Superior Health Plan CHIP/Medicaid	$14,661.34

MAJOR SMALL BOWEL PROCEDURES

Facility

$9,846.52

Service Code	APR-DRG 2302
Min. Negotiated Rate	$9,283.64
Max. Negotiated Rate	$9,846.52
Rate for Payer: Amerigroup CHIP/Medicaid	$9,283.64
Rate for Payer: Cigna Medicaid	$9,283.64
Rate for Payer: Molina CHIP/Medicaid	$9,283.64
Rate for Payer: Parkland Medicaid	$9,283.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9,846.52

MAJOR SMALL BOWEL PROCEDURES

Facility

$39,875.67

Service Code	APR-DRG 2304
Min. Negotiated Rate	$37,596.18
Max. Negotiated Rate	$39,875.67
Rate for Payer: Amerigroup CHIP/Medicaid	$37,596.18
Rate for Payer: Cigna Medicaid	$37,596.18
Rate for Payer: Molina CHIP/Medicaid	$37,596.18
Rate for Payer: Parkland Medicaid	$37,596.18
Rate for Payer: Superior Health Plan CHIP/Medicaid	$39,875.67

MAJOR SMALL & LARGE BOWEL PROCEDURES W CC

Facility

$46,652.60

Service Code	MSDRG 330
Min. Negotiated Rate	$21,484.75
Max. Negotiated Rate	$46,652.60
Rate for Payer: BCBS of TX Blue Advantage	$21,700.38
Rate for Payer: BCBS of TX Blue Essentials	$26,037.93
Rate for Payer: BCBS of TX PPO	$28,932.16

MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC

Facility

$87,842.70

Service Code	MSDRG 329
Min. Negotiated Rate	$38,447.94
Max. Negotiated Rate	$87,842.70
Rate for Payer: BCBS of TX Blue Advantage	$42,937.22
Rate for Payer: BCBS of TX Blue Essentials	$51,519.67
Rate for Payer: BCBS of TX PPO	$57,246.30

MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC

Facility

$32,467.20

Service Code	MSDRG 331
Min. Negotiated Rate	$14,574.42
Max. Negotiated Rate	$32,467.20
Rate for Payer: BCBS of TX Blue Advantage	$14,574.42
Rate for Payer: BCBS of TX Blue Essentials	$17,487.61
Rate for Payer: BCBS of TX PPO	$19,431.43

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$47,141.08

Service Code	APR-DRG 2204
Min. Negotiated Rate	$44,446.26
Max. Negotiated Rate	$47,141.08
Rate for Payer: Amerigroup CHIP/Medicaid	$44,446.26
Rate for Payer: Cigna Medicaid	$44,446.26
Rate for Payer: Molina CHIP/Medicaid	$44,446.26
Rate for Payer: Parkland Medicaid	$44,446.26
Rate for Payer: Superior Health Plan CHIP/Medicaid	$47,141.08

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$17,349.94

Service Code	APR-DRG 2203
Min. Negotiated Rate	$16,358.13
Max. Negotiated Rate	$17,349.94
Rate for Payer: Amerigroup CHIP/Medicaid	$16,358.13
Rate for Payer: Cigna Medicaid	$16,358.13
Rate for Payer: Molina CHIP/Medicaid	$16,358.13
Rate for Payer: Parkland Medicaid	$16,358.13
Rate for Payer: Superior Health Plan CHIP/Medicaid	$17,349.94

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$8,825.85

Service Code	APR-DRG 2202
Min. Negotiated Rate	$8,321.32
Max. Negotiated Rate	$8,825.85
Rate for Payer: Amerigroup CHIP/Medicaid	$8,321.32
Rate for Payer: Cigna Medicaid	$8,321.32
Rate for Payer: Molina CHIP/Medicaid	$8,321.32
Rate for Payer: Parkland Medicaid	$8,321.32
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,825.85

MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$7,226.56

Service Code	APR-DRG 2201
Min. Negotiated Rate	$6,813.46
Max. Negotiated Rate	$7,226.56
Rate for Payer: Amerigroup CHIP/Medicaid	$6,813.46
Rate for Payer: Cigna Medicaid	$6,813.46
Rate for Payer: Molina CHIP/Medicaid	$6,813.46
Rate for Payer: Parkland Medicaid	$6,813.46
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,226.56

MAJOR THUMB OR JOINT PROCEDURES

Facility

$26,786.20

Service Code	MSDRG 506
Min. Negotiated Rate	$12,128.58
Max. Negotiated Rate	$26,786.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,648.41
Rate for Payer: Amerigroup Medicare	$14,648.41
Rate for Payer: BCBS of TX Blue Advantage	$12,128.58
Rate for Payer: BCBS of TX Blue Essentials	$14,552.89
Rate for Payer: BCBS of TX Medicare	$14,648.41
Rate for Payer: BCBS of TX PPO	$16,170.50
Rate for Payer: Cigna Commercial	$15,450.85
Rate for Payer: Cigna Medicare	$14,648.41
Rate for Payer: Employer Direct Commercial	$14,648.41
Rate for Payer: Humana Medicare/TRICARE	$14,648.41
Rate for Payer: Molina Dual Medicare/Medicaid	$14,648.41
Rate for Payer: Molina Medicare	$14,648.41
Rate for Payer: Multiplan Auto	$26,786.20
Rate for Payer: Multiplan Commercial	$26,786.20
Rate for Payer: Multiplan Workers Comp	$26,786.20
Rate for Payer: Scott and White EPO/PPO	$12,335.75
Rate for Payer: Scott and White Medicare	$14,648.41
Rate for Payer: Superior Health Plan EPO	$14,648.41
Rate for Payer: Superior Health Plan Medicare	$14,648.41
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,648.41
Rate for Payer: Universal American Medicare	$14,648.41
Rate for Payer: Wellcare Medicare	$14,648.41
Rate for Payer: Wellmed Medicare	$14,648.41

MALE POST 1 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992229
Hospital Revenue Code	278
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

MALE POST 1 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992229
Hospital Revenue Code	278
Min. Negotiated Rate	$292.17
Max. Negotiated Rate	$584.34
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Commercial	$292.17
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Scott and White EPO/PPO	$584.34

MALE POST 2 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992230
Hospital Revenue Code	278
Min. Negotiated Rate	$292.17
Max. Negotiated Rate	$584.34
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Commercial	$292.17
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Scott and White EPO/PPO	$584.34

MALE POST 2 HOLE

Facility

$1,168.67

Service Code	HCPCS C1734
Hospital Charge Code	992230
Hospital Revenue Code	278
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$841.44
Rate for Payer: Amerigroup CHIP/Medicaid	$105.18
Rate for Payer: BCBS of TX Blue Advantage	$350.60
Rate for Payer: BCBS of TX Blue Essentials	$420.72
Rate for Payer: BCBS of TX PPO	$467.47
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cigna Medicaid	$841.44
Rate for Payer: Molina CHIP/Medicaid	$841.44
Rate for Payer: Multiplan Auto	$584.34
Rate for Payer: Multiplan Commercial	$584.34
Rate for Payer: Multiplan Workers Comp	$584.34
Rate for Payer: Parkland Medicaid	$841.44
Rate for Payer: Scott and White EPO/PPO	$584.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$841.44
Rate for Payer: Superior Health Plan EPO	$158.94

MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY

Facility

$1,883.30

Service Code	APR-DRG 5011
Min. Negotiated Rate	$1,775.65
Max. Negotiated Rate	$1,883.30
Rate for Payer: Amerigroup CHIP/Medicaid	$1,775.65
Rate for Payer: Cigna Medicaid	$1,775.65
Rate for Payer: Molina CHIP/Medicaid	$1,775.65
Rate for Payer: Parkland Medicaid	$1,775.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,883.30

MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY

Facility

$6,179.86

Service Code	APR-DRG 5014
Min. Negotiated Rate	$5,826.59
Max. Negotiated Rate	$6,179.86
Rate for Payer: Amerigroup CHIP/Medicaid	$5,826.59
Rate for Payer: Cigna Medicaid	$5,826.59
Rate for Payer: Molina CHIP/Medicaid	$5,826.59
Rate for Payer: Parkland Medicaid	$5,826.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$6,179.86

Know your out-of-pocket cost for care.

All Charges